Only U.S. citizens or aliens who have a legal right to work in the U.S. are eligible for employment. Can you, upon employment, provide genuine documentation establishing your identity and eligibility to be legally employed in the United States?

Yes

No

Have you ever been convicted of a crime or violation other than minor traffic infraction(s)?

Yes

No

(A conviction record will not necessarily be a bar to employment. Factors such as job relations, age and time of the offense, seriousness and nature of the violation and rehabilitation will be taken into account.)

If YES, please explain:

Have you ever been discharged from any employment or asked to resign?

Yes

No

If YES, please explain:

Please check schedule availability:

i. I am available and desire to work FULL-TIME and do not have restriction on my hours and days.

ii. I am available and desire to work PART-TIME because:______ student _____ other job _____ other. If OTHER, please explain:

Other

Employment History

Please begin with your most recent employment and continue with all past employment:

Consistent attendance and punctuality are essential requirements of every job with Penn Dutch. Is there anything which would interfere with your regular attendance and punctuality if you are offered a position with Penn Dutch?

Yes

No

If YES, please explain:

CERTIFICATION AND ACKNOWLEDGEMENT - READ CAREFULLY I certify that all answers given by me are true, accurate and complete. I understand that the falsification, misrepresentation or omission of fact on this application (or any other accompanying or required documents) will be cause for denial of employment or immediate termination of employment, regardless of when or how discovered. I authorize the references that I provide and former employers to give you any and all information concerning my previous employment they may have, personal or otherwise, and release all parties from liability for damages that may result from furnishing same to you. I understand that before any offer of employment is extended, or before employment commences, I may be required to submit to blood, urine and/or other medical testing for detection of alcohol, drugs, and/or other controlled substances in accordance with Penn Dutch policies; further, I may also be required to submit to physical agility testing as required by Penn Dutch. Additionally, I may be required by Penn Dutch to submit to a post-offer physical examination. Unsatisfactory or inconclusive results of the post-offer examination may necessitate withdrawal of the job offer. I understand as a condition of employment, I will be required to show identification which proves my legal right to work in the United States. If employed, I agree to follow the rules, regulations and other directives of Penn Dutch. I DO UNDERSTAND THAT MY EMPLOYMENT IS AT WILL AND I CAN BE TERMINATED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME, AT THE OPTION OF EITHER PENN DUTCH OR MYSELF. I understand that no company representative other than the President, or Executive Committee, has any authority to enter into any agreement to employ me for any specific period of time, or to make any agreement contrary to the foregoing. Any contrary agreement made by either the President of Executive Committee must be in writing, signed and dated. I acknowledge that no other representations have been made to me as of this date concerning employment by Penn Dutch. I have carefully read and understood the information stated above and hereby consent and agree to these conditions in exchange for consideration of my application for employment.

Yes

No

EMPLOYMENT INQUIRY RELEASE In connection with my application with Penn Dutch Food Center, I understand that background information verifications will be conducted by Penn Dutch or its agents on behalf of Penn Dutch. I understand that these verifications may include, but not be limited to, Consumer Credit Reports specifically designed for employment purposes, criminal history, civil cases in which I have been a principal, driving records, worker’s compensation claims, previous employment history, educational history (including grade point average), and other public records. I further understand that Penn Dutch or its agents may contact any current or previous employers, references, schools, government agencies or other entities for purpose of verifying the information I have provide on my employment application. I authorize, without reservation, any party or agency contacted by Penn Dutch or its agents to furnish the above mentioned information. I have read this entire document, and I understand that by signing it I am releasing all of those parties from any and all liability. Furthermore, I agree to indemnify and hold blameless and harmless both Penn Dutch and any agents acting on behalf of Penn Dutch from and against any and all claims, demands, or liabilities, including court costs and attorney’s fees. By my signature I am also voluntarily agreeing to all these conditions and giving my permission to perform this background verification. I further agree that if employed by Penn Dutch, the same stipulations as stated above will remain in effect and can be exercised at any time by Penn Dutch with or without my knowledge or additional consent. You have a right to request information regarding the nature and scope of any background verifications done on behalf of Penn Dutch concerning your application for employment by Penn Dutch. In the event that adverse action is taken as a result of information you believe to be erroneous, you must inform Penn Dutch within sixty (60) days of the time that the report is tendered. You will be provided with a copy of the disputed information and a method of contacting the reporting agency.

Yes

No

SIGNATURE OF APPLICANT:

Date

PENN DUTCH FOOD CENTER – we do not hire people and train them to be nice, WE HIRE NICE PEOPLE!